MELD = Model for End-Stage Liver Disease. MELD 22 with 10% increase every 3 months. With treatment, the MPAP should be less than 35 mm Hg and PVR should be less than 400 dynes/sec/cm −5. The patient must have pulmonary hypertension diagnosed by appropriate measurements of mean pulmonary artery pressure (MPAP), pulmonary vascular resistance (PVR), and transpulmonary gradient. MELD 28 with 10% increase every 3 months. The patient must have renal failure due to oxalate stone disease and alanine:glyoxylate aminotransferase deficiency proven by liver biopsy (sample analysis with measurement of alanine:glyoxylate aminotransferase enzyme activity and/or genetic analysis of the alanine:glyoxylate aminotransferase gene). The patient must lack significant cardiac involvement with echocardiogram showing ejection fraction greater than 40% and have ambulatory status, appropriate TTR gene mutation, and biopsy-proven amyloid. MELD 22 with 10% increase every 3 months.įamilial amyloid polyneuropathy. The patient must have FEV 1 below 40% of normal range. MELD 22 with 10% increase every 3 months as long as tumor is controlled by the treatment protocol and there is no evidence of metastases.Ĭystic fibrosis. The liver center requesting the MELD exception must have a written United Network for Organ Sharing–approved protocol that includes neoadjuvant chemoradiation and pretransplantation operative staging to exclude metastatic disease. These patients are listed with MELD 22 with 10% increase every 3 months if the Pa o 2 remains under 60 mm Hg.Ĭholangiocarcinoma. The patient must have evidence of intrapulmonary shunt and Pa o 2 below 60 mm Hg on room air. Other exceptions can include patients with the hepatorenal syndrome ( Chapter 144), the portopulmonary syndrome ( Chapter 144), cholangiocarcinoma ( Chapter 146), cystic fibrosis ( Chapters 83 and 137), familial amyloid polyneuropathy ( Chapter 179), and primary hyperoxaluria ( Chapter 194) ( E-Table 145-1). As a result, the MELD score is now adjusted for serum sodium concentration in allocating deceased donor livers (MELD-Na). Hyponatremia is an independent predictor of mortality up to a MELD score of 30. In patients with cirrhosis ( Chapter 144), hyponatremia ( Chapter 108) is associated with hepatorenal syndrome, ascites, and death from liver disease. This allocation system has improved transplantation rates and has not altered waiting list or post-transplantation mortality. Patients with acute liver failure or post-transplantation patients with graft failure due to hepatic artery thrombosis have a MELD score of 40 and top priority status. In addition, the SHARE 35 rule allows for regional sharing of a donor liver to a regional patient with a score of 35 or higher. As a result, deceased donor livers must be made available more broadly if no local patient has a MELD score of 15 or higher. A patient’s survival is not improved by deceased donor liver transplantation if the MELD score is below about 15. The 3-month mortality rate increases from 10% with a MELD score of 20 to 60% at a MELD score of 35, and essentially to 100% with a MELD score above 40. liver transplantation candidates and the allocation of deceased donor livers are based on the MELD or MELD-Na score (see Table 144-2 in Chapter 144), which ranges from 6 (best prognosis) to 40 (worst prognosis). Lee Goldman MD, in Goldman-Cecil Medicine, 2020 Assigning Priority: Model for End-Stage Liver Disease
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